Treatment of Childhood Pneumonia

Treatment of childhood pneumonia in developing countries
59
X4
Treatment of childhood pneumonia
in developing countries
Hasan Ashraf, Mohammod Jobayer Chisti and Nur Haque Alam
Clinical Sciences Division, International Centre for Diarrhoeal Disease Research,

Bangladesh (ICDDR,B)
Bangladesh
Introduction
Definition of community acquired pneumonia (CAP)
CAP can be defined clinically as the presence of signs and symptoms of pneumonia in a
previously healthy child due to an acute infection (of less than 14 days duration) of the
lower respiratory tract (usually occurs below terminal bronchioles) leading to cough or
difficult breathing, tachypnoea, or lower chest-wall indrawing, which has been acquired in
the community outside hospital (Zar et al., 2005; BTS, 2002). In developed countries this can
be verified by the radiological finding of consolidation (BTS, 2002). In resource poor setting
of the developing world, a more practical term - acute lower respiratory infection (ALRI) - is
preferred, reflecting the difficulties in obtaining a chest radiograph, especially in rural areas
(BTS, 2002).
Disease burden and epidemiology of CAP
In the developing world, pneumonia is not only more common than it is in Europe and
North America (Riley et al.,1983; Berman & McIntosh, 1985; Selwyn, 1990), but also more
severe and is the largest killer disease of children (Bulla & Hitze, 1978; Baqui et al., 1998).
The fourth Millennium Development Goal has concentrated efforts on addressing the
priority areas for improving child survival worldwide, with an aim of reducing the national
child mortality rates by two-thirds by 2015 (UN, 2000). ALRI, particularly pneumonia, are
currently the leading and biggest single cause of deaths among under-5 children 1 to 59
months of age in the developing countries (UNICEF & WHO, 2006; Graham et al., 2008),
being responsible for at least 19% of the annual 8.8 million deaths in this age-group
(Wardlaw et al., 2006). ALRI causes more than 2 million child deaths (one million in children
aged 1 to 59 months and additional one million in neonates) worldwide each year, mostly
from pneumonia, accounting for 20% of deaths in under-5 children (Bryce et al., 2005; Rudan
et al., 2004), and 90-95% of all these deaths occur in the developing countries (Rudan et al.,
2008; Murray & Lopez, 1997; Garenne et al., 1992; Mulholland, 1999; Williams et al., 2002;
WHO, 1998). In terms of magnitude of the problem, there is an estimated incidence of 151
million new cases of pneumonia each year globally, and 11-20 million (7-13%) are severe
enough to require hospitalization in the developing countries (Rudan et al., 2004; Rudan et
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al., 2008). Recent estimates also suggest that 1.9 million (95% CI 1.6 to 2.2 million) children
died from acute respiratory infection (ARI) throughout the world in 2000 and 70% of them
occurred in Africa and Southeast Asia, one dying in every 7 seconds (Mulholland, 1999;
Williams et al., 2002). Actually, CAP is a major cause of health care utilization,
hospitalization, and death in children in the developing countries (Mulholland, 1999;
Williams et al., 2002; WHO, 1998). Therefore, improvement in the case-management
strategies of the major causes of child death, such as pneumonia and neonatal illnesses in
developing countries, should be a priority in improving the child survival in the developing
countries (Walley et al., 2008; Duke & Tamburlini, 2003). ARI is also a major cause of visits
to the outpatient and emergency departments as well as admissions to the hospitals.
Although bronchiolitis, tracheobronchitis and pneumonia, each accounts for one-third of
ALRI cases, pneumonia is responsible for most of the ALRI deaths. In Bangladesh, ALRI
account for 25% of deaths among under-5 children and constitute 40% of all infantile deaths
(Baqui et al., 1998). In a study conducted at the Dhaka Hospital of ICDDR,B among 401
under-5 children with ALRI, it was observed that the most common manifestation was
pneumonia and a respiratory pathogen (both bacterial and viral) was identified in 30% cases
and the case fatality rates were 14% in bacterial pneumonia and 3% in viral pneumonia
(Rahman et al., 1990). In another study also conducted at the Dhaka Hospital of ICDDR,B
among 601 under-5 children with ALRI, it was observed that the most common
manifestation was pneumonia (86.5%), and a viral pathogen was detected in 21% cases, and
the overall case fatality rate was 6.8%, and that of viral pneumonia was 4.8% (Huq et al., 1990).
Objective
To develop guidelines for the physicians and nurses of the developing countries for the
diagnosis and management of CAP in children
Options
Clinical assessment
Radiographic assessment
Laboratory testing
Empirical antimicrobial therapy

Outcomes
Increased awareness of the age-related causes of CAP including those children

with severe acute malnutrition (SAM), and those with dehydrating diarrhoea
Improved accuracy of clinical diagnosis of CAP in children
Better utilization of the available diagnostic testing
Rational use of empirical antimicrobial therapy
Decreased morbidity and mortality due to CAP

Benefits, harms, and costs
Increased awareness of the causes of paediatric pneumonia
Accurate diagnosis
Prompt treatment
Reduced cost associated with unnecessary investigations and complications due to

inappropriate treatment
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Rationale
As pneumonia is a major cause of morbidity and mortality in children in the developing
countries (Williams et al., 2002), early and appropriate treatment of pneumonia can reduce
the morbidity and mortality (Sazawal & Black, 2003), which has been the rationale for the
development of guidelines for the management of CAP (Zar et al., 2005). The guidelines also
aim to provide recommendations for effective therapy and to minimize the development of
bacterial resistance through judicious use of antibiotics (Zar et al., 2005). This document
aims to provide guidelines for the diagnosis and effective management of children with
CAP so as to improve pneumonia-associated morbidity and mortality, thereby improving
the case-management strategies of the major cause of child death, such as pneumonia in the
developing countries which should be a priority in improving child survival globally
(Walley et al., 2008; Duke & Tamburlini, 2003).
Clinical classification and management plan of CAP
Depending on the clinical presentation, pneumonia can be classified as very severe, severe,
or non-severe according to the World Health Organization (WHO) (WHO, 1990; WHO,
1984; WHO, 2000; WHO, 1991). The specific treatment guidelines for each of them, and the
diagnosis of pneumonia should primarily be based on the visible clinical parameters,
including respiratory rate and lower chest-wall indrawing (WHO, 1990; WHO, 1991; Cashat
et al., 2005). Pneumonia is usually caused by viruses or bacteria, but the most serious
episodes are caused by bacteria. However, in the absence of clear cut demarcation for
aetiological diagnosis of pneumonia on the basis of clinical and/or radiological features,
empiric antibiotic therapy is needed for all cases of CAP. Hospitalization of children with
severe pneumonia is recommended for giving supportive treatment including
oropharyngeal or nasopharyngeal suction, oxygen therapy for hypoxaemia, fluid and
nutritional management, and close monitoring (WHO, 1990; WHO, 1984; WHO, 2000; WHO,
1991). Therefore, management of severe childhood pneumonia relies on hospital-based
treatment, but practical barriers often prevent children in areas with highest rates from
receiving hospital care (Ashraf et al., 2008). In the developing countries, there are not
enough paediatric beds in hospitals for admission of all severe cases of pneumonia (Ashraf
et al. 2008). In addition, hospitalization may not be possible because of the inability of the
parents to visit the hospital because of the long distances to travel or financial or other
domestic reasons, such as the need to care for siblings at home and the need for the mother
to work (Ashraf et al., 2008; Ashraf et al., 2007). It is, therefore, important to provide some
form of institutional care for children who cannot be hospitalized, at least until stabilization
of their acute condition (Ashraf et al., 2008). Radiological examination and determination of
hypoxaemia by pulse oximetry, have been recently considered as the optimal methods for
diagnosing pneumonia. But, they are clearly suitable only for use in the institutional settings
like the day-care centres or out-patient clinics. Two prospective observational studies have
shown that the day-care facility-based, modified primary care management of severe
childhood pneumonia (Ashraf et al., 2008) and severe acute malnutrition (SAM) (Ashraf et
al., 2007) is successful and cost-effective as an alternative to hospitalization. Provision of
broad-spectrum antibiotics and appropriate supportive care during a stay at established
day-care centre during their working hours, followed by the continuation of care at home at
night, is an effective alternative to hospitalization of children with severe pneumonia
without associated co-morbidities such as SAM (Ashraf et al., 2008). The results of this study
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indicate that severe childhood pneumonia without SAM can be successfully managed on a
day-care basis at established day-care clinics, if adequately trained and motivated staff and
the necessary logistic support can be made available (Ashraf et al., 2008). The results of a
randomized controlled clinical trial (RCT) have shown that in a select group of under-5
children with severe pneumonia, without associated co-morbidities such as SAM, can be
safely and effectively managed on a day-care basis as effectively as the hospital set-up
management, except those children with hypoxaemia requiring prolonged oxygen therapy
for more than six hours, and that day-care based treatment option is less expensive than
hospital-care (Ashraf et al., 2010). The results also indicate that severe pneumonia without
hypoxaemia can be successfully managed on a day-care basis at a day-care clinic, however,
identification of those severely pneumonic children having hypoxaemia requiring
prolonged oxygen therapy for more than six hours are necessary, as they are at increased
risk of death and therefore need to be hospitalized for support and care for a longer period
of time (Ashraf et al., 2010). These results would have great impact in the treatment and care
of childhood pneumonia, particularly in resource-poor countries where hospital beds are
scarce. It can be easily replicated in most urban and rural out-patient clinics and day-care
centres, provided that proper training and motivation of the staff as well as provision of
logistic support are guaranteed. The additionally needed funds are well invested facing the
lower costs of the day-care treatment model compared to those of hospital-care (US$ 114 vs.
178) (Ashraf et al., 2010). However, policy and programme changes would be necessary to
add such components to the out-patient clinics and day-care centres, and this would require
additional human and financial resources, which is not an easy task. Therefore, this would
be important in selecting the intervention for wider implementation in national
programmes. The results of our RCT identified a way to more efficiently use scarce hospital
beds in developing countries by selecting out children with severe pneumonia for the daycare management, who following existing guidelines, would have been identified as the
ones requiring hospitalization. This would be a practical approach in developing countries a smaller investment in upgrading the day-care facilities through development of trained
resources and procurement of some supporting equipment, which could pay back in a much
greater way.
Rapid/fast breathing (WHO)
Rapid/fast breathing is defined as when the age-specific respiratory rates become
60/minute in neonates and infants aged <2 months, 50/minute in infants aged 2 to <12
months, and 40/minute in children aged 12-59 months, as shown below:
Age < 2 months: 60/minute
Age 2 to <12 months: 50/minute
Age 12 months-5 years: 40/minute
(N. B. A child who is exactly 12 months old would have fast breathing if s/he breaths
40/minute. Tachypnoea is the best single predictor of pneumonia in children of all ages).
Lower chest-wall indrawing
Indrawing of the chest wall is a manifestation of reduced lung compliance resulting from
the tendency of declining intra-alveolar pressure due to pneumonic consolidation or
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airways obstruction. WHO recommends the use of lower chest wall indrawing as a sign of
pneumonia requiring admission to hospital, defined as the inward movement of the bony
structures of the lower chest wall with inspiration. Lower chest-wall indrawing is also called
subcostal indrawing/subcostal retractions
Clinical types of pneumonia (WHO)
Very severe pneumonia (up to 5 years)
Severe pneumonia (up to 5 years)
Pneumonia (not severe) (only for children aged 2 months to 5 years)
No pneumonia: cough or cold (up to 5 years)
Very severe pneumonia
If a child with cough or difficult breathing has any one or more of the following danger
signs, s/he is classified as having very severe pneumonia (WHO, 2005)
Not able to drink
Cyanosis
Head nodding
No danger signs are defined as the absence of all of the following danger signs: not able to
drink/feed, central cyanosis, head nodding, stridor in calm child, abnormally sleepy,
convulsion, and severe clinical malnutrition.
If a child presents with severe malnutrition with any sign of pneumonia (any of the WHO
defined signs of pneumonia or severe pneumonia or very severe pneumonia or crackles or
bronchial breath sound in lungs or radiological pneumonia) should be considered as very
severe pneumonia.
Severe pneumonia
Severe pneumonia is defined as an young infant (< 2 months ) with cough or difficult
breathing having fast breathing and/or lower chest-wall indrawing, or a child (2 months to
5 years) with cough or difficult breathing having only lower chest-wall indrawing.
Pneumonia (not severe)
Pneumonia (not severe) is defined as a child (2 months to 5 years) with cough or difficult
breathing having only fast breathing, but no lower chest-wall indrawing, or no signs of very
severe pneumonia.
Aetiology of CAP
Rational treatment for pneumonia depends on knowing the most likely pathogens in each
community, as the relative frequency of different agents may vary from one geographical
region to another and depends on the age of the patient, vaccination status, immunological
status, relevant exposure and clinical setting at which pneumonia was acquired. Mixed
bacterial and viral infections may occur in 30-40% of cases of CAP (Zar et al., 2005).
Streptococcus pneumoniae is the most common bacterial cause of childhood pneumonia (BTS,
2002)), followed by Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae,
and Mycobacterium tuberculosis. The less common bacterial causes are Staphylococcus aureus,
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Bordetella pertussis, Pneumocystis jiroveci (previously known as Pneumocystis carinii), and

Niserria meningitidis. In older children, when a bacterial cause is found, it is most commonly
Streptococcus pneumoniae followed by Mycoplasma and Chlamydia (BTS, 2002). Viruses are the
most common causes of pneumonia in younger children (infancy, pre-school and school age
children), except neonates (BTS, 2002). In neonates, the most common causes are Group B
streptococcus beta haemolyticus (GBB), Escherichia coli, Klebsiella pneumoniae, Chlamydia
trachomatis (3-19 weeks), Cytomegalovirus (CMV), and the less common causes are
Staphylococcus aureus, Listeria monocytogenes, and Pseudomonas. The common viruses are
Respiratory Syncytial Virus (RSV), influenza, and parainfluenza viruses, adenovirus, and
human metapneumovirus (HMV).
The spectrum and frequency of causative agents of bacterial pneumonia in severely
malnourished children often differs in pneumonic children without severe malnutrition
(Chisti et al., 2009).
Table 1. Causes of CAP according to various age groups and SAM
All age groups
Bacteria are the major causes of CAP in children
1. Streptococcus pneumoniae: commonest
2. Haemophilus influenzae (including Hib & nontypable strains)
3. Staphylococcus aureus
Atypical bacteria*
4. Mycoplasma pneumoniae* (> 5 years)
5. Chlamydia pneumoniae*
6. Chlamydia trachomatis* (3-19 weeks)
7. Moraxella catarrhalis
Gram-negative bacteria**
8. Klebsiella pneumoniae**
9. Escherichia coli**
10. Pseudomonas**
Viruses***
11. Respiratory syncytial virus (RSV)***
12. Influenza A or B***
13. Parainfluenza virus types 1, 3***
14. Adenovirus***
15. Human metapneumovirus (HMV)***
16. Rhinovirus***
17. Coronavirus***
18. Enterovirus***
19. CMV***
20. Pneumocystis jiroveci (previously known as Pneumocystis carinii)
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0-2 months
1. Group B streptococcus
Gram-negative bacteria**
2. Klebsiella pneumoniae**
3. Escherichia coli**
4. Pseudomonas**
6. Chlamydia trachomatis*
7. Listeria monocytogenes
8. Viruses***
9. Ureaplasma urealyticum
10. Bordetella pertussis
2 months-5 years
1. Viruses***
2. Streptococcus pneumoniae
3. Haemophilus influenzae (including Hib & nontypable strains) (Common in developing
countries where vaccination is still not widely used)
5. Mycoplasma pneumoniae*
Above 5 years
1. Streptococcus pneumoniae
2. Haemophilus influenzae (including Hib & nontypable strains)
Atypical bacteria*
4. Mycoplasma pneumoniae*
5. Chlamydia pneumoniae*
6. Viruses***
SAM
1. Klebsiella pneumonia** (26%)
2. Staphylococcus aureus (25%)
3. Streptococcus pneumoniae (18%)
4. Escherichia coli** (8%)
5. Haemophilus influenzae (including Hib) (8%)
6. Salmonella species**
7. Pseudomonas**
8. Acinetobacter species**
9. Methicillin-resistant Staphylococcus aureus (MRSA)
10. Pneumocystis jiroveci (previously known Pneumocystis carinii)
11. CMV***
12. Candida
(N.B.
* indicates atypical bacteria
indicates viruses)
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** indicates gram-negative bacteria ***
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Risk factors for CAP

Some risk factors for CAP are shown below (Zar et al., 2005; Chisti et al., 2009)
Host factors
Infancy (Age <1 year)
Prematurity
Low birth weight (including low weight for age)
Malnutrition
Immunosuppression
Social/environmental
Overcrowding
Air pollution
Inadequate housing
Low socioeconomic status
Passive exposure to tobacco smoke
Indoor fuel exposure
Winter season
Lack of breast feeding
Failure to complete immunization
Attendance at day-care centres
Presence of coughing sibling (s) at home

Pneumonia in SAM
The WHO defines malnutrition as the cellular imbalance between the supply of nutrients
and energy and the energy and the bodys demand for them to ensure growth, maintenance,
and specific functions (de Onis et al., 1993). Among the four principal causes of deaths in
young children worldwide, undernutrition has been ascribed to be the cause of death in
60.7% children with diarrhoeal diseases, 52.3% of those with pneumonia (Caulfield et al.,
2004). More than half of all the childhood deaths are associated with malnutrition (Rice et
al., 2000). Pneumonia is common in malnourished children and frequently associated with
fatal outcome (Bryce et al., 2005; Rice et al., 2000; Loeb & High, 2005; Nannan et al., 2007). Of
children with malnutrition requiring hospital admission, up to two-thirds are diagnosed
with pneumonia (Shimeles & Lulseged, 1994; Ahmed et al., 1999). A most recent systematic
review revealed those children with pneumonia and moderate or severe malnutrition are at
higher risk of death (Chisti et al., 2009). For SAM, the relative risks ranged from 2.9-121.2
with odds ratios ranged from 2.5-15.1. For moderate malnutrition, the relative risks ranged
from 1.2-36.5 (Chisti et al., 2009). The clinical classification of pneumonia based on the
diagnostic criteria according to the WHO guidelines should be carefully evaluated in
children with SAM. A Gambian study evaluated that the respiratory rate cut-off required in
malnourished children should be taken approximately 5 breaths per minute less than that in
well nourished children and this finding may be related to the lower body temperatures
found in severely malnourished children with pneumonia (Falade et al., 1995). Similarly,
intercostal indrawing was more common and lower chest wall indrawing was less common
in severely malnourished children (Falade et al., 1995; Chisti et al., 2010). In addition, lower
chest wall indrawing is not sufficiently sensitive as predictors of pneumonia in SAM and no
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visible clinical signs are consistently reliable for the diagnosis of pneumonia in SAM.
Malnourished children may not have the strength to manifest some of these physical signs
in the same manner as well nourished children (Falade et al., 1995; Chisti et al., 2010).
Moreover, data from a recent systematic review suggest that a reliance on simple clinical
signs will underestimate the burden of the disease and potentially delay the diagnosis of
pneumonia in severely malnourished children (Chisti et al., 2009). Therefore, WHO
recommends that children with SAM who present with cough, fast or difficult breathing
irrespective of having clinical signs of pneumonia or not, should be treated with appropriate
antibiotics to save the lives of these high-risk group of children (Falade et al., 1995).
Occult pneumonia is another entity characterized by the absence of the clinical signs and
may be diagnosed by performing a chest radiograph; it may occur in SAM with dehydrating
diarrhoea (Hall & Simon, 1987; Murphy et al., 2007; Bachur et al., 1999). The typical clinical
signs of pneumonia may be absent in SAM due to sub-optimal inflammatory responses,
reduced power of the respiratory muscles, and depletion of potassium and magnesium
(Suskind et al., 1990). SAM also contributes to immune deficiency and reduced host defense.
Pneumonia with dehydrating diarrhoea
The clinical classification of pneumonia based on the diagnostic criteria according to WHO
should be carefully evaluated in children presenting with dehydrating diarrhoea caused by
Vibrio cholerae, ETEC, as well as rotavirus. If a child presents with severe or some degree of
dehydration, then s/he would likely to have acidosis, which is responsible for the
development of tachypnoea and it would be very difficult to distinguish clinically whether the
increased respiratory rate is due to pneumonia, or due to acidosis, or both. In this situation, it
is generally recommended to fully rehydrate the child first with IV/oral fluid (according to the
type of dehydration present) within 4-6 hours and then count the respiratory rate for detecting
pneumonia according to the standard WHO guideline. It is also recommended to perform a
chest radiograph after full hydration of the patient for confirming the diagnosis of pneumonia.
Diagnosis of CAP
The diagnosis of CAP should be considered in any child who has an acute onset of respiratory
symptoms, particularly cough, fast breathing, or difficulty in breathing. Diagnosis includes
clinical evaluation, radiographic evaluation and etiological investigations to: (i) establish whether
pneumonia is present; (ii) assess the severity of pneumonia; (iii) determine the clinical type of
pneumonia; and (iii) determine the causative organism. In general, diagnostic investigations to
determine the cause of pneumonia are indicated only in children requiring hospitalization
(Zar et al., 2005). Bacterial pneumonia cannot be reliably distinguished from viral pneumonia on
the basis of any single parameter: clinical, laboratory, or chest radiographic findings.
Clinical evaluation
Radiographic evaluation
Aetiological investigations
Pulse oximetry
The best objective measurement of hypoxaemia is by pulse oximetry which avoids the need
for arterial blood gases. Oxygen saturation (Sao2) measurements provide a non-invasive
estimate of the arterial oxygenation (BTS, 2002). The human eye is poor in recognizing
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hypoxaemia. Even under ideal conditions, skilled observers cannot consistently detect
hypoxaemia until the oxygen (O2) saturation is below 80% (Comroe & Bothello, 1947). Pulse
oximetry is probably one of the most important advances in monitoring the respiratory
problems and these instruments have a reasonable degree of accuracy (Jurban, 1999). The
pulse oximeter is easy to use and requires no calibration. However, it requires a pulsatile
signal from the patient. When using paediatric wrap around probes, the emitting and
receiving diodes need to be carefully opposed. It is also highly subject to motion artifacts. To
obtain a reliable reading (i) the child should be resting, still and quiet, not crying or irritable
(Zar et al., 2005; BTS, 2002); (i) a good pulse signal (plethysmograph) should be obtained;
and (iii) once a signal is obtained, the saturation reading should be watched over at least 30
seconds and a value recorded once an adequate stable trace is obtained (Zar et al., 2005; BTS,
2002). Pulse oximetry as a potentially useful diagnostic tool for the detection of hypoxaemia
as an indicator of severe pneumonia; have not been sufficiently evaluated for the diagnosis
of children with SAM (WHO, 2005). Widespread use of pulse oximetry is now
recommended for monitoring children with severe pneumonia in the developing countries.
Perhaps the major challenge facing pulse oximetry is whether this technology can be
incorporated effectively into the diagnostic and management algorithms that can improve
the efficiency of clinical management of CAP in the developing countries (Jurban, 1999).
Significance of hypoxaemia with CAP and its management
Assessment of oxygenation is important in the evaluation of a child with pneumonia and
pulse oximetry should be performed in every child admitted to a hospital with CAP (Zar et
al., 2005; BTS, 2002). Hypoxaemia is defined as the arterial oxygen saturation of less than
90% in room air at sea level as recorded by the pulse oximetry, which is the most serious
manifestation of childhood pneumonia (Weber et al., 1997). In white patients, an SPO2 target
of 92% resulted in a satisfactory level of oxygenation, whereas a higher SPO2 target of 95%
was required in black patients (Jurban, 1999; Jurban & Tobin, 1990). Alternatively, no
hypoxaemia is defined as the arterial oxygen saturation of 90% in room air as recorded by
the pulse oximetry. The median prevalence of hypoxaemia in WHO-defined pneumonia
requiring hospitalization (severe and very severe pneumonia) was 13% but the prevalence
varied widely (Subhi, 2009). This corresponds to at least 1.5 to 2.7 million annual cases of
pneumonia with hypoxaemia presenting to the health-care facilities (Subhi, 2009). WHO
recommends for children older than 2 months, the use of oxygen in severe/very severe
pneumonia, as ascertained by the presence of a number of clinical indicators of hypoxaemia,
including cyanosis, inability to drink, severe lower chest wall indrawing, respiratory rate
greater than 70 breaths per minute, grunting respiration, or head nodding (WHO, 2005).
Head nodding is a movement of the head synchronous with each breath, which is caused by
increased use of auxiliary muscles of respiration and therefore indicates severe respiratory
distress and an important clinical sign predicting hypoxaemia (Weber et al., 1997). Only one
Gambian study showed that hypoxaemia could be predicted in only half of the children by
the presence of a combination of three clinical signs, such as extreme respiratory distress,
cyanosis, and severely compromised general status (Weber et al., 1997). Agitation may be an
indication that the child is hypoxaemic (BTS, 2002). Hypoxaemia is also a good indicator for
detecting the severity of pneumonia (Wang et al., 1995; Hall et al., 1979; Shann et al., 1989). It
is a common complication of childhood infections, particularly ALRI, and case fatality rate
of pneumonia is inversely related to the arterial haemoglobin oxygen saturation (SaO2)
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(Onyango et al., 1993). In pneumonia - a disease that disproportionately impacts the

developing countries, hypoxaemia is an important risk factor for death (Onyango et al.,
1993; Duke et al. 2000), as hypoxaemic children are five times more likely to die than nonhypoxaemic children. In patients admitted with pneumonia to a general medical service, it
was found that O2 saturation <90% of at least 5 minutes duration occurred in 26% of the
patients (Bowton et al., 1994). On follow-up over the next 4-7 months, those patients
experiencing hypoxaemia during the first 24 hour of hospitalization had more than a
threefold higher mortality than patients who did not desaturate (Bowton et al., 1994).
In the critical care setting especially for evaluating the progress of children suffering from
severe pneumonia, pulse oximetry is also used as one of the most commonly employed
monitoring modalities in the critical care setting especially for evaluating the progress of
children suffering from severe pneumonia (Jurban, 1999). Moreover, hypoxaemia is also an
important risk factor for failure to the day-care management as well as the need for future
follow-up admissions (Ashraf et al., 2010). Therefore, measurement of oxygen saturation
should be routinely done in all children with severe pneumonia with pulse oximetry, and
those with hypoxaemia requiring prolonged oxygen therapy for more than six hours should
be referred to a hospital for long-term oxygen therapy (Ashraf et al., 2010). Results of that
study were consistent with earlier reports that hypoxaemia in pneumonic children are
predictors of severe disease and is a risk factor for death (Onyango et al., 1993; Duke et al.,
2000). Hypoxaemia has been overlooked in world-wide strategies for pneumonia control
and reducing child mortality (Subhi, 2009). It is also often overlooked in the developing
countries, mainly due to the low accuracy of clinical predictors and the limited availability
of pulse oximetry, despite of its more accurate detection of hypoxaemia and oxygen therapy
for treatment (Subhi, 2009). Many more people do not have access to the health care
facilities. Oxygen therapy in developing countries continues to be a low priority on the child
health agenda (Subhi, 2009). Oxygen was never mentioned in the recent publication by the
WHO and UNICEF efforts to control pneumonia (Wardlaw et al., 2006). The accurate
detection of hypoxaemia is important as delivery of oxygen to the hypoxaemic children may
improve the outcome. Especially in a setting where oxygen has to be bought in cylinders, a
pulse oximeter might be a cost effective purchase, as it allows identification of children who
are in need of oxygen, and the amount of oxygen given can be titrated to the actual need of
the patient, thus avoiding unnecessary wastage of valuable oxygen (Weber et al., 1997).
There is now evidence that ensuring ample supplies of oxygen and promoting a routine and
systematic approach of screening for hypoxaemia by using pulse oximetry is associated with
improved quality of care and reduced mortality, and that the technology required to do so is
affordable and sustainable in district level hospitals and day-care centres in the developing
countries (Duke et al., 2000, Dobson et al., 1996; Duke et al., 2008; Dobson, 1991; Steinhoff &
Black, 2007; Matai et al., 2008). Pulse oximetry would enable accurate identification of
hypoxaemia and might increase the safety and cost effectiveness of this recommendation
and this diagnostic tool should be included. This was demonstrated by our recent study
reporting successful day-care case management of severe pneumonia using pulse oximetry
as an important part of the treatment algorithm (Ashraf et al., 2008). Hypoxaemia is a very
common and treatable complication of childhood pneumonia in developing countries and it
is a recognized predictor of severe disease and a risk factor for death and correlates with
disease severity. For home management to be safe and ethical, it is essential that only
children without hypoxaemia are managed outside health-care facilities (Subhi et al., 2009).
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Children with hypoxaemic pneumonia requiring prolonged oxygen therapy for more than
six hours, need to be identified (which is often difficult using only clinical signs), admitted,
and given supplemental oxygen for prolonged duration, and close monitoring (Ashraf et al.
2010). The measurement of SpO2 as a regularly measured vital sign by using pulse oximetry
should be incorporated as an important part of the treatment algorithm for improving the
diagnosis of hypoxaemia, and categorizing the severity of pneumonia (Onyango et al., 1993;
Steinhoff & Black, 2007; Lozano et al., 1994; Weber & Mulholland, 1998). For treating
children with pneumonia, there is an urgent need to increase the widespread availability as
well as use of pulse oximetry for monitoring patients with severe pneumonia and effective
oxygen delivery systems in the developing countries.
Classification of hypoxaemia
There are two ways of classifying hypoxaemia in children: (i) WHO classification and (ii)
British Thoracic Society (BTS) classification as defined below:
(i)
WHO classification of hypoxaemia
Experts from WHO often classifies hypoxaemia as mild, moderate and severe as defined below:
Mild hypoxaemia: when the arterial oxygen saturation lies between 85 to 90%, the
patient is known to have mild hypoxaemia.
Moderate hypoxaemia: when the arterial oxygen saturation lies between 80 to 85%,
the patient is known to have moderate hypoxaemia.
Severe hypoxaemia: when the arterial oxygen saturation is less than 80%, the
patient is known to have severe hypoxaemia.
(ii) BTS classification of hypoxaemia

Similarly, experts from paediatric respiratory medicine in developed countries including
BTS often categorized hypoxaemia as mild, moderate and severe as defined below:
Mild hypoxaemia: when the arterial oxygen saturation lies between 88 to 92%, the
patient is known to have mild hypoxaemia.
Moderate hypoxaemia: when the arterial oxygen saturation lies between 85 to 88%,
the patient is known to have moderate hypoxaemia.
Severe hypoxaemia: when the arterial oxygen saturation is less than 85%, the
patient is known to have severe hypoxaemia.
Indications for oxygen therapy

1. Hypoxaemia (oxygen saturation <90% in room air at sea level)
2. Central cyanosis
3. Severe lower chest-wall in-drawing
4. Grunting respiration
5. Restlessness (due to hypoxaemia)
6. Inability to drink or feed
7. Respiratory rate >70 breaths/min
8. Head Nodding
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Management of hypoxaemia
Oxygen should be available at any health care facility where sick children are seen
regularly. Oxygen therapy reduces mortality associated with severe pneumonia. It
should be given to children who are restless, who had tachypnoea with severe
lower chest wall in-drawing, head nodding, cyanosis, or not tolerating oral feeds.
The SpO2 should be maintained above 92%.
If oxygen is required infrequently then cylinders are the most practical source of
oxygen. Cylinders also allow oxygen therapy to be used while the patient is
transferred to a facility with more resources.
If oxygen is used more frequently, then oxygen concentrators are the preferred
source of oxygen.
In hospitals with oxygen supplies, wall oxygen units should be available.
Low flow meters must be available to give appropriate oxygen flow to children. In
most hospitals these will be variable orifice units, but fixed orifice units may be
more practical in some units.
Key messages about hypoxaemia in relation to CAP (WHO, 2009)
Hypoxaemia is a common complication in ALRI in children, and is a strong
risk factor for death.
At least 13% of children presenting to hospitals with severe or very severe
pneumonia have hypoxaemia, and the rates are much higher in some
hospitals; some exceeding 50%.
The prevalence of hypoxaemia is higher in referral hospitals than in primary

care settings. Hypoxaemia is more common at higher altitude, in younger
ages and in certain geographical regions.
SpO2 <90% is the most clinically useful definition of hypoxaemia and is

considered by most clinicians as an appropriate indication for giving
oxygen.
If pulse oximetry is available only at the time of admission, screen all
patients if time allows, or those patients with any clinical signs of
hypoxaemia, including all children with emergency or priority signs.
If oximetry is used at outpatient triage, screen all children with any

emergency or priority signs.
Any child with an SpO2 <90% should receive oxygen.
Use oximetry, at least daily, to check any patients who are already on
oxygen, and screen any patient who develops any emergency signs or
shows other clinical signs of deterioration.
Explain the meaning of oximetry to parents. This will help them understand
the importance of oxygen and other treatments and will involve them in
their childs care.
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Health Management
Children should not be discharged until their SpO2 has been stable at 90% or
more while breathing room air for at least 24 hours, until all emergency
and priority signs have resolved, and until appropriate home treatment
can be organized.
Methods of oxygen administration
Nasal prongs: are recommended for most children. Nasal prongs give a
maximum fractional concentration of inspired oxygen (F1O2) of 28-35%
except in small infants when higher concentrations may be obtained. This
method does not require humidification of oxygen and ensures that the
child receives oxygen during feeding. Oxygen flow rates of 0.5-1 l/minute
are required in children less than 2 months old and 2-3 l/minute in infants
and children aged 2 months to 5 years.
Nasal catheters: are usually well tolerated and humidification is not

required, but they can be blocked by mucous. Oxygen via nasal catheters
gives a maximum F1O2 of 35-40%.
Nasopharyngeal catheters: have the advantage of requiring the lowest

flow rate to achieve a given oxygen concentration in the airways. Infants
under the age of 2 months can usually be treated with 0.5 minute and
infants up to 1 year with 1 minute. However, humidification of oxygen is
required and the catheter may be easily blocked. Further, potentially
lethal complications including gastric distension, airway obstruction,
apnoea, pneumo-orbitus and pneumocephalus may occur. Continuous
skilled nursing is therefore necessary to prevent these complications.
Consequently, oxygen administration via nasopharyngeal catheter is not
recommended.
Headbox: oxygen is well tolerated by young infants. Headbox oxygen

requires no humidification but requires a high flow and a mixing device
to ensure the correct F1O2 is delivered. This is the least preferred method as
there is wastage of oxygen and delivered F1O2 is unpredictable.
Facemask: oxygen is designed to deliver 28%-65% oxygen at a flow rate of

6-10 minutes.
Polymask: In severely hypoxaemic infants who are not ventilated, oxygen

should be administered using a polymask whereby F1O2 concentrations of
60-80% may be achieved. The flow rate should be regulated to keep the
bag of the mask inflated during inspiration and expiration.
Using the prone position for infants may improve hypoxaemia and the
respiratory system compliance (Chaisupamongkollarp et al., 1999) and
should be attempted if hypoxaemia is difficult to treat.
Oxygen should be discontinued when the child is improving and the

transcutanous saturation is above 90% in room air, as recorded by the
pulse oximetry.
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Radiological diagnosis
Radiological changes may be vague or inconclusive or even absent despite the presence of
clinical signs of pneumonia (Doherty, 1991; Hamid et al., 1996; Wafula et al., 1998: Chisti et
al., 2009). Conversely, clinical signs of pneumonia can be absent in the presence of
radiological signs of pneumonia (Murphy et al., 2007; Bachur et al., 1999; Chisti et al., 2009).
There are two main clinical definitions of pneumonia based on the radiological findings:
Bronchopneumonia is defined as a febrile illness with cough, respiratory distress with
evidence of localized or more than one or generalized patchy infiltrates on the chest x-ray.
Lobar pneumonia is defined as a febrile illness with cough, respiratory distress with an
illness similar to that of bronchopneumonia, except that the physical findings (affected lobe
reveals woody dull on percussion, rales, increased vocal resonance and/or bronchial breath
sound on auscultation) and radiographic examination indicate lobar consolidation.
Occult pneumonia: It was observed that approximately 25% of the febrile children defined
as the rectal temperature becoming more than 380 Celsius (Ashraf et al., 2010), with a WBC
count >20,000/mm3, but without any lower respiratory tract findings on examination, had
radiographic evidence of pneumonia, known as occult pneumonia, commonly found in
children with SAM and children with dehydrating diarrhoea (Murphy et al., 2007; Bachur et
al., 1999; Chisti et al., 2009).
Limitations of chest radiography
Less useful in discriminating the causative pathogens
Cannot accurately discriminate viral from bacterial pneumonias (Swingler, 2000).
Wide range of inter- and intra-observer variation in the interpretation (Swingler,

2001; Bada et al., 2007; Pauls et al., 2007; Sarria et al., 2003), not only among the
paediatricians, but also among the radiologists, even paediatric radiologists
Does not result in the improved outcome or change in the treatment of ambulatory
settings (Swingler et al., 2000)
Indications for CXR
To confirm the presence of pneumonia
To detect clinical pneumonia, unresponsive to the standard ambulatory

management
To identify suspected cavitations or military mottling in PTB
To identify suspected foreign body aspiration
To identify hospitalized children for the detection of local complications of

pneumonia, such as pleural effusion, pneumothorax, empyema thoracis, advanced
stage of bronchiectasis, and lung abscess
High fever, leukocytosis with no obvious focus of infections (26% such cases may
have radiographic pneumonia) (Bachur et al., 1999).
Children developing secondary heart failure
Children with congenital problems, such as Congenital Heart Disease (CHD), cystic
fibrosis, Downs Syndrome
Children with re-current attacks of pneumonia
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Health Management
Indications for follow-up CXR
Children with lobar collapse

To document the resolution of a round pneumonia (as this may mimic the
appearance of a Ghon focus)
Children with ongoing respiratory symptoms
Children with re-current attacks of pneumonia
General tests of infection

They may not be useful to differentiate bacterial from viral pneumonia (Nohynek et al.,
1995; Toikka et al., 2000; Korppi et al., 2003)
WBC count, neutrophil count (PMN leukocytosis suggests bacterial pneumonia (Marks &
Klein, 1995; Klein, 1992) and lymphocytic leukopenia suggests viral pneumonia) (Austrian
& Gold, 1964)
C-reactive protein (>40 mg suggests bacterial infection)
ESR
Procalcitonin
Copeptin
Blood culture: to identify the causative bacterial pathogen, that is possible in only less than
30% (10-30%) of cases of CAP (Donowitz & Mandell, 1990), and to determine its sensitivity
Pleural fluid: if present, should be aspirated and investigated for specific infectious agents
The C-reactive protein, ESR, procalcitonin, and copeptin are the non-specific markers for the
diagnosis of pneumonia.
Indications for hospital admission
1. Hypoxaemia (oxygen saturation <90% in room air at sea level)
2. Toxic appearance
3. Respiratory rate >70/minute, or severe respiratory distress
4. Infants < 2 months
5. Impaired level of consciousness
6. Inability to drink or eat
7. Cyanosis
8. Stridor in calm child
9. Chronic lung disease
10. Systemic manifestation
11. Intermittent apnoea
12. Grunting respiration
13. Severe lower chest-wall indrawing
14. SAM
15. Family unable to provide adequate care/non-compliant parents
16. Failure to respond ambulatory care/no response to previous oral antimicrobial therapy
17. Clinical deterioration on treatment
18. Immunocompromised host/immunodeficiency
19. Recurrent pneumonia
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Indications for transfer and admission to Paediatric Intensive Care Unit (PICU)
1. Needs ventilator support
2. Failure to maintain a saturation of >90% with oxygen therapy
3. Apnoea or slow irregular breathing
4. Severely acidotic patient
5. Exhaustion with rising respiratory rate and pulse rate
6. Patient is in shock
Differential diagnosis of a child with cough, or difficult breathing
Diagnosis
Points in favour
1. Pneumonia
Fast breathing
Lower chest wall indrawing
Crepitations on auscultation
Bronchial breathing
Nasal flaring
Grunting respiration
Head nodding
2. Cardiac failure
Tachycardia
Tachypnoea
Enlarged tender liver
Dependent oedema
Raised jugular venous pressure
Central cyanosis
Heart murmur
Gallop rhythm
3. Pneumothorax
Sudden onset
Sudden onset of unexplained tachypnoea and
respiratory distress (disproportionate to the severity of
pneumonia)
Hyper-resonance chest on the affected side on percussion
Shift of mediastinum (trachea, apex beat to opposite side)
Diminished or absent breath sound on auscultation on
the affected side
4. Pleural effusion, empyaema
Stony dull on percussion (it is difficult to elicit in young

child)
Diminished breath sound on the affected side of lesion
Shift of mediastinum (trachea, apex beat to opposite side)
5. Pericardial effusion
Oedema feet
Raised jugular venous pressure
Apex beat not visible/not palpable
Increased area of cardiac dullness
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Health Management
Heart sound (muffled or absent)

Pulsus paradoxus
Enlarged liver
Pneumonia in older children often present in many ways
The following two classic presentations have been described for pneumonia (Jadavi et al.,
1997)
Typical presentation (predominantly respiratory signs)
Fever
Chills
Pleuritic chest pain
Productive cough
Fast breathing
Cyanosis
Atypical presentations (single or in combinations) gradual onset over several days to weeks:
Nonproductive cough
Low-grade fever
Headache
Malaise
Meningism
Acute abdominal pain
Acute pain in chest or shoulder
Convulsion
Antibiotic use in the treatment of CAP
When treating CAP, the clinical, laboratory and radiographic findings should be considered,
especially when the child is hospitalized. As it is difficult to distinguish bacterial from viral
pneumonia and because of the frequency of mixed bacterial-viral infections (30-40%) (Zar
et al., 2005), all children with CAP would require an antibiotic. The age of the child,
nutritional status, immunologic status of the host, local epidemiology of respiratory
pathogens, and sensitivity of these pathogens to particular antimicrobial agents and the
emergence of antimicrobial resistance usually play a big role to determine the choice of
antibiotic therapy. The severity of pneumonia and the drug costs also have a great impact on
the selection of antimicrobial therapy, particularly in the developing countries. The
management of a child with CAP involves a number of decisions regarding treatment with
antibiotics (BTS, 2002).
Whether to treat with antibiotics?

Which antibiotic and by which route?
When to change to oral treatment?
Total duration of antibiotic therapy;
When to change antibiotic and why?
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Outpatient management
In children with mild pneumonia (non-severe pneumonia), the breathing is fast, but there is
no lower chest wall indrawing. Oral antibiotics at an appropriate dose for an adequate
duration are effective for treatment. The mother is advised to return in two days for
reassessment, or earlier if the child appears to deteriorate.
Antimicrobial agent
Recommended dosage
Route
Comment
Neonate (0-4 weeks)
1st line of
I/V
100 mg/kg/day 12 hourly
Ampicillin plus
I/V
treatment
Gentamicin
2nd line of
I/V
75-100 mg/kg/day 8 hrly
Ceftazidime plus
I/V
treatment
Flucloxacillin
Infants > 4-8 weeks
Ampicillin plus
I/V
1st line of
Gentamicin
I/V
treatment
2nd line of
I/V
75-100 mg/kg/day od
Ceftriaxone plus
I/V
treatment
Gentamicin
Infants >8 weeks to children of 5 years plus above 5 years
Amoxicillin
Oral
1st line of
treatment
Azithromycin
10 mg/kg/day once daily
Oral
2nd line of
treatment
Ceftriaxone
75-100 mg/kg/day od
I/V
3rd line of
treatment
Severe pneumonia with SAM
1st line of
I/V
Ampicillin plus
I/V
treatment
Gentamicin
2nd line of
I/V
75-100 mg/kg/day od
Ceftriaxone plus
I/V
treatment
Gentamicin
3rd line of
I/V
Ceftazidime plus
I/V
treatment
Flucloxacillin
Suspected Staph aureus pneumonia
1st line of
I/V
Amoxicillin plus
I/V
treatment
Flucloxacillin
(Oxacillin/ 100 mg/kg/day 6 hourly
Nafcillin for MRSA)
2nd line of
I/V
75-100 mg/kg/day od
Ceftriaxone plus
I/V
treatment
Flucloxacillin
(Clindamicin/Vancomycin for
MRSA)
Vancomycin
10 mg/kg iv 8 hourly
I/V
3rd line of
treatment
Table 2. Antimicrobial treatment of CAP
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Ceftazidime plus
Ciprofloxacillin
Co-trimoxazole (SXT)
Health Management
Suspected pseudomonas pneumonia

I/V
100 mg/kg/day 8 hrly
I/V
Suspected PCP pneumonia
Oral
20 mg/kg loading dose
followed by 10 mg/kg in 2
divided doses or, 20
mg/kg/day in 4 divided
doses
1st line of
treatment
1st line of
treatment.
Therapy to be
continued for at
least 14 days
(sometimes 21
days)
Suspected hospital acquired pneumonia

a) For early onset HAI (if HAI occurs < 96 hours of admission)
1st line of
I/V
Fluroquinolone
(e.g. 20 mg/kg/day in 2
Ciprofloxacin)
plus divided doses
treatment
aminoglycosides
(e.g.
I/V
Gentamicin)
2nd line of
3rd generation cephalosporin
I/V
treatment (HAI
e. g. Ceftriaxone Monotherapy 75-100 mg/kg/day od
where we dont
with Fluroquinolone
I/V
suspect Staph)
3rd line of
3rd generation cephalosporin
I/V
75-100 mg/kg/day od
treatment (HAI
e. g. Ceftriaxone plus
I/V
where we suspect
Flucloxacillin
Staph)
b) For late onset HAI (if HAI occurs > 96 hours of admission)
1st line of
Anti-pseudomonal penicillin
I/V
50
mg/kg/dose
(Ticarcillin
treatment
(e. g. Ticarcillin/clavulanic
base: max. 3.0 gm/dose) 6
acid) plus
Anti-MRSA
(e.
g. hourly
I/V
10 mg/kg iv 8 hourly
Vancomycin)
2nd line of
Anti-pseudomonal
treatment
cephalosporin
(e.
g.
I/V
Ceftazidime) plus
Aminoglycosides with wide
I/V
coverage (e.g. Amikacin), or 6 mg/kg/day 12 hourly
I/V
Anti-MRSA
(e.
g. 10 mg/kg iv 8 hourly
Vancomycin)
Duration of antibiotic treatment

Antibiotic therapy is generally recommended for 5 to 7 days for uncomplicated cases of
childhood pneumonia (Zar et al., 2005; Mehta, 2003). For suspected Staphylococcus aureus
infection, the duration of treatment may be extended for 14 to 21 days, depending on the
clinical response. Gram-negative bacilli, or Legionella species, may also require longer
courses of therapy for 10 to 21 days (BTS, 2002; Mehta, 2003). Alternatively, the newer
macrolides such as azithromycin may be used for 3-5 days (Zar et al., 2005). In case of
neonates, the treatment should be continued for at least 2 weeks. If pneumonia is
complicated with empyema, the treatment should be continued for at least 4 weeks.
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Switching from parenteral therapy to oral therapy is a key management issue for childhood
pneumonia. Children receiving parenteral therapy for 2 to 4 days can usually be switched to
oral therapy provided there is clinical improvement as children becoming afebrile defined
as the rectal temperature becoming 380 Celsius or less and remaining so for at least 24 hours
(Ashraf et al., 2010), they can tolerate medication orally, they do not have any diarrhoea and
vomiting and have no relevant local complications of pneumonia (Shalit et al., 1994; Dagan
et al., 1994). Switching over to oral antibiotics will help for early discharge from the hospital
and subsequently prevent hospital acquired infection and vacant hospital beds for other sick
children.
Indications for the use of antipyretics and analgesics in CAP
Rectal temperature >390 Celsius
There is a known risk of febrile convulsions
There is central nervous system pathology that may be aggravated by high fever
Children with CAP are generally pyrexial and may also have some pain, including
headache, chest pain, arthralgia (in cases of Mycoplasma pneumoniae), referred abdominal
pain, and possibly earache from associated otitis media. Pleural pain may interfere with the
depth of breathing and may impair the ability of the child to cough. Antipyretics and
analgesics can be used to keep the child comfortable and to help coughing. Minimal
handling helps to reduce metabolic and oxygen requirements and this should be considered
when planning and carrying out procedures, investigations, and treatments. Pain associated
with pneumonia may be due to pleurisy or to pathology involving the upper airways. Pain
or discomfort should be treated as it may severely compromise respiratory function and
adequate clearance of secretions. The most appropriate agent is paracetamol at a dose of 15
mg/kg/dose given 4-6-hourly orally or 20-40 mg/kg/dose per-rectally for two-three times
daily. If this dose does not provide adequate analgesia, a mixture of paracetamol and
codeine (0.5 mg/kg/dose 8-hourly) is very effective. Aspirin is contraindicated in most
children because of the association with Reyes syndrome (Zar et al., 2005).
Calorie requirements
Adequate nutrition is of particular concern, especially when there are underlying factors
such as malnutrition. A minimum of 50-60 kcal/kg/day should be given to a child with
pneumonia with continuation of regular breast feeding for breast-fed children. A calorie
intake of 80-100 kcal/kg/day should be given to a non-breast fed child with CAP. Ensuring
adequate calorie intake is essential as there is an excessive demand on the energy reserves in
children with pneumonia, in whom the work of breathing is increased. Children should not
be starved for more than 24 hours to prevent the development of hypoglycaemia. In the
presence of malnutrition, and following several days of poor nutrition, this needs to be
increased considerably. In the early phase of pneumonia, ketosis should be avoided by
ensuring adequate carbohydrate intake. With time, a greater proportion of intake can be
lipids. The intake of calories should be adequate to meet the metabolic requirements and to
promote growth.
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Health Management
Enteral feeds
Children with pneumonia should be encouraged to feed orally unless there are indications
for nasogastric feeding/intravenous fluid infusions. If children are too distressed to take
fluid and feeds orally, continuous enteral feeds via a nasogastric tube may be provided.
Indications for N/G tube feeding
Too distressed to drink or swallow safely
Having frequent severe coughing episodes that may be associated with vomiting
and possible aspiration of gastric contents
Hypovolaemia with associated poor peripheral perfusion (may even require I/V
fluid)
Painful oral sore/condition which interfere with feeding by mouth

Fluid therapy
Children with uncomplicated pneumonia should receive normal maintenance fluids.
Appropriate rehydration is required in children who are dehydrated. Oral intake should
cease when a child is in severe respiratory distress. In severe pneumonia, inappropriate
secretion of anti-diuretic hormone (ADH) is increased (Dhawan et al., 1992), dehydration is
therefore uncommon. It is important that the child should not be over hydrated. A study of
264 hospitalized children with CAP in India has shown hyponatraemia on admission in 27%
cases and it was calculated that, in 68% of these children, the hyponatraemia was secondary
to inappropriate ADH secretion (SIADH) (Singhi & Dhawan, 1992). Treatment is with fluid
restriction.
Intravenous fluids must be used with great care and with caution, and only if adequate
monitoring is available (Zar et al., 2005). Children who are vomiting or who are severely ill
may require intravenous fluids. These should be given at 80% of the basal levels (once
hypovolaemia has been corrected). In children with severe or complicated pneumonia,
serum urea and electrolytes should be measured before instituting I/V fluids as among
them (SIADH) is common. In these children, fluid intake should be restricted to 40-60% of
normal requirements, i.e. 50 ml/kg/day of I/V fluids. They should be frequently monitored
as severely ill children with CAP might develop SIADH as a recognized complication
(Dhawan et al., 1992; Singhi & Dhawan, 1992).
Indications for I/V fluid
Shock
Inability to tolerate enteral feeds
Sepsis
Severe dehydration
Gross electrolyte imbalance
Hypoglycaemia
Monitoring of the child with CAP
The following parameters should be routinely monitored in every child with CAP, the
frequency of which will depend on the severity of illness as well as the availability of
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resources. Special attention should be given to child receiving I/V fluid therapy and those
with SAM.
Heart rate
Respiratory rate
Temperature
Respiratory pattern including chest recession
Use of accessory muscles
Establishment of oral feeding
Liver size
Oxygen saturation level
Chest auscultation: rales, rhonchi, bilateral basal crepitation, pleural rub
Fluid and calorie intake
Children on oxygen therapy should have at least 4-hourly observations of all the above
parameters and children without getting oxygen should be observed at least 12-hourly.
If a child remains pyrexial or unwell 48 hours after admission with pneumonia, reevaluation is necessary with consideration given to exclude possible local complications
of CAP (BTS, 2002).
Micronutrient supplementation
In children with CAP, as an adjuvant therapy with antibiotics, 20 mg of Zinc po daily until
discharge was found to accelerate the recovery from severe pneumonia, reducing the
duration of hypoxaemia (Brooks et al., 2004; Shakur et al., 2004; Mahalanabis et al., 2002).
Zinc should therefore be considered for use in children hospitalized with CAP, particularly
if there is co-existing SAM. Zinc also reduces the incidence of pneumonia, especially in
children with SAM. But, studies from Vellore, India showed that zinc has no significant role
to reduce the morbidity and mortality in children with acute severe pneumonia (Bose et al.,
2006). Zinc should therefore be considered cautiously for use in children hospitalized with
CAP.
Non-response to therapy
If a child remains pyrexial or unwell 48 hours after admission with CAP, re-evaluation is
necessary with consideration given to the possible complications:
Inappropriate drug (antibiotic): in relation to choice of antibiotic, adequate

dosage, route of administration, and duration of antibiotic therapy
Development of local lung complications of CAP such as pleural effusion,
empyema, lung abscess, bronchieactasis, pneumothorax, liver abscess etc.
Immunosuppression
Coexisting disease such as cystic fibrosis, chronic suppurative bronchitis,
congenital heart disease (CHD), Downs Syndrome
Underlying SAM: slow, delayed and poor response to conventional antibiotic
therapy
Underlying TB (PTB, miliary TB, disseminated TB, TBM)
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Health Management
Underlying malignancy
Underlying HIV infection
Development of heart failure
Metastatic infection can rarely occur as a result of the septicaemia associated
with CAP. Osteomyelitis or septic arthritis should be considered, particularly
with Staph aureus infections.
Incorrect diagnosis of CAP
Complications of CAP
Fortunately, most children with CAP recover without any complication
Persistent effusions and empyemas are the most common serious complications of
bacterial pneumonia
Pulmonary abscess
Respiratory distress
Sepsis (bacteraemia may occur in 10-30% cases of pneumonia; sepsis in <10% cases
especially in SAM)
Tension pneumothorax (very rare: less than 1%)

Patient education
Parents should be cautioned to look for the signs of increasing respiratory distress,
danger signs of very severe pneumonia, clinical signs of hypoxaemia and advised
to seek medical attention immediately if any of these signs appear
Most children with CAP treated with outpatient antibiotics will be much improved
within 48 hours after the initiation of treatment. If such improvement does not
occur, medical attention should be sought.
Medicolegal Pitfalls
Attempting to treat neonates and very young infants on an outpatient basis
Failure to recognize and treat signs of respiratory compromise, heart failure, and
sepsis
Failure to recognize and treat associated SAM
Failure to give parents clear discharge instructions

Measures of no value in the treatment of CAP
Chest physiotherapy: The function of chest physiotherapy is to assist the removal

of tracheobronchial secretions resulting in an increase of gas exchange and
reduction in work of breathing. However, trials have found no clinically
discernible benefit or impact of chest physiotherapy on the course of illness in
bronchiectasis, cystic fibrosis, pneumonia, bronchiolitis, asthma, acute atelectasis,
inhaled foreign body and post extubation babies. There is no evidence to support
the use of chest physiotherapy including postural drainage, percussion of the chest,
or deep breathing exercises that should be routinely performed in children with
uncomplicated CAP (Levine, 1978; Britton et al., 1985; Stapleton, 1985; Wallis &
Prasad, 1999). There is a suggestion that physiotherapy is counterproductive, with
patients who receive chest physiotherapy being at risk of having a longer duration
of fever than the control group (Britton et al., 1985). In addition, there is also no
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evidence to show that physiotherapy is beneficial in the resolving stage of

pneumonia (Wallis & Prasad, 1999). Therefore, chest physiotherapy is not
beneficial and should NOT be routinely prescribed for children with CAP. A
supported sitting position may help to expand the lungs and improve the
respiratory symptoms in children with respiratory distress. Chest physiotherapy
only works in children with pneumonia having chronic lung disease (cystic
fibrosis, suppurative chronic lung disease, primary ciliary dyskinesia).
Mucolytic agents: Anti-tussive remedies are not recommended as they cause
suppression of cough and interfere with airway clearance. Adverse effects and
overdose have been reported. Therefore, they should not be advised in children
with CAP.
Postural drainage: There is no evidence for the use of a head-down position for
postural drainage.
Nebulized bronchodilators: Nebulized bronchodilators or saline do not improve
the outcome of CAP.
Cortocosteroids: There is no evidence to support the use of oral or inhaled
corticosteroids in CAP.
References
Ahmed T, Ali M, Ullah MM et al. Mortality in severely malnourished children with
diarrhoea and use of a standardised management protocol. Lancet 1999;353:191922.
Ashraf H, Ahmed T, Hossain MI, Alam NH, Mahmud R, Kamal SM, Salam MA, Fuchs GJ.
Day-care management of children with severe malnutrition in an urban health
clinic in Dhaka, Bangladesh. J Trop Pediatr 2007;53:171-8.
Ashraf H, Jahan SA, Alam NH, Mahmud R, Kamal SM, Salam MA, Gyr N. Day-care
management of severe and very severe pneumonia, without associated comorbidities such as severe malnutrition, in an urban health clinic in Dhaka,
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Health Management
Edited by Krzysztof Smigorski
ISBN 978-953-307-120-6
Hard cover, 112 pages
Publisher Sciyo
Published online 27, September, 2010
Published in print edition September, 2010

Possibilities of medical intervention have thrived over the last decades. Our knowledge about mechanisms of
the development of diseases and factors influencing it has increased. Effective treatment requires a holistic
approach that takes into consideration aspects at first sight not related to a course of a specific disorder. This
book contains a few chapters focusing on issues related to health management. The chapters are arranged in
an order reflecting multidimensionality of issues constituting this theoretical and practical area - starting from
the studies focusing on a general, administrative level, to considerations related to situations of individuals
suffering from a specific illness. The discussed problems concern different age groups - children, adults and
the elderly. We hope that readers professionally engaged in healthcare - both theoretically and clinically - will
find it interesting, useful and inspiring.
How to reference
In order to correctly reference this scholarly work, feel free to copy and paste the following:
Hasan Ashraf, Mohammud Jobayer Chisti and Nur Haque Alam (2010). Treatment of Childhood Pneumonia in
Developing Countries, Health Management, Krzysztof Smigorski (Ed.), ISBN: 978-953-307-120-6, InTech,
Available from: http://www.intechopen.com/books/health-management/treatment-of-childhood-pneumonia-indeveloping-countries
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Treatment of Childhood Pneumonia

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Treatment of Childhood Pneumonia

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Treatment of childhood pneumonia in developing countries

Clinical Sciences Division, International Centre for Diarrhoeal Disease Research,

Empirical antimicrobial therapy

Increased awareness of the age-related causes of CAP including those children

Improved accuracy of clinical diagnosis of CAP in children

Better utilization of the available diagnostic testing

Rational use of empirical antimicrobial therapy

Decreased morbidity and mortality due to CAP

Increased awareness of the causes of paediatric pneumonia

Reduced cost associated with unnecessary investigations and complications due to